Laserfiche WebLink
Waste Tire Sur may & Inspection Report Inspection Report Number ■ <br /> e11 State of California I 1 <br /> Survey Form 1127738 <br /> CIWMB 181(New 04/04) <br /> - Page 1 <br /> California Integrated Waste Management Board - <br /> BLUE OR BLACK INK PEN <br /> Part A- Survey <br /> Business Profile Inspection Details <br /> TPID- ' � r� � � / � - � � Inspection Type (Fill one) <br /> Site Suffix: Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: Say, J0f1LlUI O C(-)U,f\, 1 Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name A <br /> J Inspected By Inspector <br /> A , A- + &a1 __lL0e11 r Inc_ <br /> Physical Address 3 1Q(1 E� i(7 <br /> a`3,Ovl - <br /> sh&kon GA "irDa\5 Inspection Date <br /> Time In Time Out ) <br /> Business Rep Title I O AM O AM <br /> ( <br /> 40 PM 1 S ® 46 PM <br /> - - ---- -- - - - - --- -- -- -Operational Status Tire Type Business Role Storage Type <br /> (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> Tire Count(Whole/PTE) 9 � ffl a <br /> Active • Passenger Generator Q Outdoor <br /> O Q Closed Q Altered MIA <br /> GPS Latitude Q Hauler Q Indoor <br /> O ii Q Inactive 0 Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) _ <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility I ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. I Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§ 18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities _- <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators • in Compliance - No Violations <br /> Q Q Other: § <br /> Comments lI <br /> --�1D-V��u�ot\S__Dr Acus -07t <br /> C.s; ausf1 <br /> rQ. cu- A i T� -Imp�►�A � WV <br /> Inspection Form Included- <br /> Comments InclQ <br /> Bu s Ina ure Phone Number Inspe t is Signatur � Phone Number <br /> - - _ - �-- <br /> . ' X A F f 2 3 62081 <br /> ■ INSTRUCTIONS ON BACK Correct. _ Incorrect. i V� ® ■ <br /> White Copy:CIWMB Yellow Copy:Operator Pink opy: <br />